Re: [Sepsis Groups] Sepsisgroups Digest, Vol 270, Issue 1
Dr. Westover - AMEN Isn't it a physician's job to know about changes in vital signs, mental status, or organ function? There is something seriously wrong with some of these people. They deserve early diagnosis and treatment whether it's sepsis or not. If we welcome rather than resist reporting, we'll miss fewer of these opportunities. Ron Elkin, MD Pulmonary/Critical Care California Pacific Medical Center San Francisco On Mon, Nov 27, 2017 at 5:33 PM, Thomas Westover <twest54...@yahoo.com> wrote: > I find it interesting (and somewhat misguided) that people are trying to > reduce the frequency of "false alarm" alerts... (acknowledging that alarm > fatigue is a real entity!!!) > > The whole point of a sepsis (or any) screening tool is to have a HIGH > sensitivity (ie NOT miss true cases) at the expense of firing off false > alarms (ie low specificity) > > You dont want to reduce alerts.. you dont want to use "predictive > analytics" to hone down who is affected vs who is false alarm... that is > NOT the goal of the initial screening tool > > You want the screening tool to be highly sensitive (ie "never" miss a true > sepsis case); a positive screen will then aim the focus of the clinical > team/physicians etc to more carefully evaluate the pt for progressive > sepsis. So its the subsequent evaluation AFTER a positive screen that hones > down who is true positive vs who is false positive > > You can easily make the screening tool more specific (ie fewer false > alarms) by creating a screening tool that will only pick up pts that are > about to die from sepsis (altered mental status, grossly abnl vitals, > severe shock, etc) but then the screening tool is ineffective at its > intended goal; which is to alert the clinical team that the pt is starting > to deteriorate NOT that the pt is about to arrest > > the surviving sepsis campaign has struggled with these concepts for years > (trying to balance sensitivity vs specificity); It's not their fault, its > the nature of the beast of screening tools > > Respectfully > > Thomas Westover MD, FACOG > Asst Professor MFM and Obgyn > Cooper Medical School, Rowan University > Vice Chair, NJ ACOG > Co-Chair, NJ Hospital Association Statewide Perinatal Safety Collaborative > Camden NJ > > > -- > *From:* "sepsisgroups-requ...@lists.sepsisgroups.org" < > sepsisgroups-requ...@lists.sepsisgroups.org> > *To:* sepsisgroups@lists.sepsisgroups.org > *Sent:* Monday, November 27, 2017 12:49 PM > *Subject:* Sepsisgroups Digest, Vol 270, Issue 1 > > Send Sepsisgroups mailing list submissions to > sepsisgroups@lists.sepsisgroups.org > > To subscribe or unsubscribe via the World Wide Web, visit > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups- > sepsisgroups.org > > or, via email, send a message with subject or body 'help' to > sepsisgroups-requ...@lists.sepsisgroups.org > > You can reach the person managing the list at > sepsisgroups-ow...@lists.sepsisgroups.org > > When replying, please edit your Subject line so it is more specific > than "Re: Contents of Sepsisgroups digest..." > > > Today's Topics: > > 1. Re: [**External**] Re: Sepsis Best Practice Alerts > (Barnes-Daly, Mary Ann, MS, RN, CCRN, DC) > > > -- > > Message: 1 > Date: Fri, 17 Nov 2017 16:10:42 + > From: "Barnes-Daly, Mary Ann, MS, RN, CCRN, DC" > <barne...@sutterhealth.org> > To: "Orth, Claudia" <cor...@mhc.net>, jenny clarke <j...@live.com>, > "Tara Miller" <tara.mil...@infirmaryhealth.org> > Cc: "sepsisgroups@lists.sepsisgroups.org" > <sepsisgroups@lists.sepsisgroups.org> > Subject: Re: [Sepsis Groups] [**External**] Re: Sepsis Best Practice > Alerts > Message-ID: > <DM5PR11MB1372A81FF4E069CE10B616E1F32F0@DM5PR11MB1372. > namprd11.prod.outlook.com> > > Content-Type: text/plain; charset="utf-8" > > At Sutter Health we have several: > First is ?possible sepsis? for Infection (active culture, problem list) > plus available SIRS > Second is ?possible severe sepsis? ? same as above plus available organ > dysfunction (excludes BUN/Cr for example for ESRD) > Third is ?possible septic shock? - above with Lactate > 4 > > 1 and 2 fire only for RNs 3 fires for RN, and providers > > We are moving toward predictive analytics(PA) ? and may or may not > continue with BPAs ? or just go to PA alerts where the recipient doesn?t > need to be in the chart to be notified, as with a BPA > > Thanks, > > MARY ANN BARNES-DALY MS R
Re: [Sepsis Groups] [**External**] Sepsis Alert
The study showed worse physiologic derangements and ED survival in arrest patients that were bacteremic, but survivals were not different at 28 days or beyond. I don't see a comparison of outcomes for bacteremic patients who received antibiotics in ED versus those that did not. The criteria for a diagnosis of severe sepsis or septic shock have included suspicion of infection (susceptible to the biases of the observer), SIRS (not sensitive or specific but quite likely in arrest both with or without sepsis), and evidence of acute organ dysfunction related to infection (but common in arrest with or without sepsis). For the individual patient, a significant challenge would be to distinguish between arrest only, arrest with severe sepsis/septic shock, and arrest with coincidental bacteremia insufficient to cause severe sepsis/septic shock. Organ failure, lactate, and procalcitonin, the latter two sometimes elevated in severe physiologic stress of any kind, will not provide this distinction for the individual patient. Therefore,one can make a good case for excluding these patients from analysis in the larger group of patients with severe sepsis/septic shock without arrest, or at least restricting the analysis to arrest patients. Thanks for the discussion. Ron Elkin San Francisco On Fri, May 19, 2017 at 7:19 AM, Townsend, Sean, M.D. < towns...@sutterhealth.org> wrote: > The interesting thing is that the original proposal was to delete these > patients from your data, but based on Ron’s sleuthing, they may actually be > a real part of the data. As a practical matter, it’s one of the last > things docs will be thinking of in this situation. > > > > Arguing for antibiotics in these cases at a minimum is not a bad idea. > > > > Sounds like all providers will be affected equally with this problem, so > I’m not worried from a data perspective, but interesting effort to provide > education around antibiotics in post-arrest situations. > > > > *From:* Cynthia Wells [mailto:cynthia.we...@steward.org] > *Sent:* Friday, May 19, 2017 7:04 AM > *To:* Ron Elkin <elkin@gmail.com>; Townsend, Sean, M.D. < > towns...@sutterhealth.org> > *Cc:* sepsisgroups@lists.sepsisgroups.org > *Subject:* RE: [Sepsis Groups] [**External**] Sepsis Alert > > > > Hello, > > I definitely agree.. In order to meet the sepsis bundle we would still > need the other two criteria- suspicion of infection/SIRS, hence we should > start abx earlier to if nothing else prevent progression if arrest not > related to bacteremia. I am concerned about the fluids because most of > these lactates are sky high they are automatically pulled into shock > elements. > > > > Cindy > > > > Cynthia Wells > > Steward Health Care > > Director of Clinical Performance Analytics > > (508) 404-8647 > > > > *From:* Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org > <sepsisgroups-boun...@lists.sepsisgroups.org>] *On Behalf Of *Ron Elkin > *Sent:* Thursday, May 18, 2017 10:43 PM > *To:* Townsend, Sean, M.D. <towns...@sutterhealth.org> > *Cc:* sepsisgroups@lists.sepsisgroups.org > *Subject:* Re: [Sepsis Groups] [**External**] Sepsis Alert > > > > Attached is a study showing a 38% incidence of bacteremia in ED patients > presenting with out of hospital cardiac arrest. It is often unclear if the > bacteremia was a contributing cause, or a result of the arrest, but the > study suggests we should have a low threshold for instituting immediate > empirical antimicrobial therapy in these patients. > > > > Such patients will certainly complicate diagnosis, treatment, and outcomes > if included in analysis of severe sepsis or septic shock unassociated with > arrest. > > > > Ron Elkin MD > > San Francisco > > > > > > > > On Wed, May 17, 2017 at 10:56 AM, Townsend, Sean, M.D. < > towns...@sutterhealth.org> wrote: > > I would agree this is a confounder. You could delete from your local focus > study, but they will still hit the metric for purposes of SEP-1. I'm not > sure how often you see this to justify a change to SEP-1, but if common I'd > take a look. > > > On May 17, 2017, at 10:52 AM, Mary Draper <mary.dra...@johnmuirhealth.com> > wrote: > > Hi Dr. Townsend, I have been looking through the Severe Sepsis guidelines > with regards to patient who present in cardiac arrest to the ED. I have not > found any information specific to this issue. Most of them have an > elevated lactate. It is difficult to determine what was the cause of the > arrest. We are proposing to our Sepsis committee that we delete these > patients from the focus study. > What are your thoughts on this subject? > Thanks > > Mary Draper R
Re: [Sepsis Groups] VBG for screening
Sorry for my misinterpretation of your question, Rick. I work in a hospital where house staff and others often order a peripheral vbg solely for venous saturation, erroneously using the result to guide resuscitation instead of obtaining central or mixed venous saturation. There's a useful summary of the relative values of VBGs vs ABGs in UptoDate - "Venous blood gases and other alternatives to arterial blood gases" - with a caution regarding PvCO2 in shock states. The difference between PvCO2 and PaCO2 widens with severity of shock and can be substantial. An elevated PvCO2 may therefore indicate shock, hypercarbia, or some combination thereof. Mixed forms and subtle degrees of shock can be difficult to recognize at the bedside. The authors also caution: "Importantly, sufficient variability between arterial and venous blood gas values may exist such that periodic correlation between arterial and venous blood gas values is always prudent." Peripheral venous O2 saturation cannot replace central or mixed venous saturation as a guide to resuscitation. On one hand, rapid peripheral VBG analysis may spare a patient an arterial puncture to assess pH, pCO2, and HCO3; on the other hand, interpretation of that peripheral VBG may be more complicated than realized. I'm unaware of studies addressing the relative accuracies of interpretation, effects on outcome, value as an addition to screening panels, or prognostic implications of peripheral VBGs in particular. Arguably, neither ABGs nor VBGs are necessary to manage many patients with sepsis. Look forward to seeing other opinions. Thanks Ron On Nov 30, 2015 9:14 PM, "Rutherford, Richard" < richard.rutherf...@ventura.org> wrote: > > Hi Doctor Elkin, > > > Thanks for your response. The advocates of VBG at my hospital are not proposing to use peripheral blood to follow SVO2 but rather to have access to peripheral venous pH, HCO3, pCO2 and electrolytes in five minutes instead of an hour. They feel it could lead to earlier recognition of critical illness especially in mixed situations (hypercarbia respiratory failure AND septic shock for example). At our hospital it would not add cost or resource time, and it makes some intuitive sense to me but I am unaware of any emergency departments using this strategy. I appreciate your thoughts. > > > Rick > > > Richard Rutherford, M.D. > Quality Medical Director, Ventura County Medical Center > 3291 Loma Vista Road, Ventura, CA 93003 > (805) 665-8234 (cell) > (805) 652-6096 (office) > > > > From: Ron Elkin <elkin@gmail.com> > Sent: Monday, November 30, 2015 7:10 PM > To: Rutherford, Richard > Cc: sepsisgroups@lists.sepsisgroups.org > Subject: Re: [Sepsis Groups] VBG for screening > > > Hi Richard, > > VBG must be obtained from central access point - junction of RA and SVC or from pulmonary artery - to permit interpretation. Most patients lack central access at time they are screened. VBG from a peripheral vein is of little or no value. > Central saturation and CVP before resuscitation (forgive me for this blasphemy) - if readily available from a dialysis catheter, PICC or port - may help guide the resuscitation effort, or at least make you think twice about your patient. > > Hope this helps. > > Ron Elkin MD > California Pacific Medical Center > San Francisco > > On Nov 30, 2015 2:21 PM, "Rutherford, Richard" < richard.rutherf...@ventura.org> wrote: >> >> Hello all, >> >> >> My hospital is considering expanding our sepsis screening so that a VBG+Lactate is checked for every patient with a positive sepsis screen (instead of lactate alone). Have any other hospitals done this? Does anyone have a second set of criteria for sicker patients for whom VBG is ordered? >> >> >> Thanks, >> >> >> Richard Rutherford, M.D. >> Quality Medical Director, Ventura County Medical Center >> 3291 Loma Vista Road, Ventura, CA 93003 >> (805) 665-8234 (cell) >> (805) 652-6096 (office) >> >> ___ >> Sepsisgroups mailing list >> Sepsisgroups@lists.sepsisgroups.org >> http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org >> ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] VBG for screening
Hi Richard, VBG must be obtained from central access point - junction of RA and SVC or from pulmonary artery - to permit interpretation. Most patients lack central access at time they are screened. VBG from a peripheral vein is of little or no value. Central saturation and CVP before resuscitation (forgive me for this blasphemy) - if readily available from a dialysis catheter, PICC or port - may help guide the resuscitation effort, or at least make you think twice about your patient. Hope this helps. Ron Elkin MD California Pacific Medical Center San Francisco On Nov 30, 2015 2:21 PM, "Rutherford, Richard" < richard.rutherf...@ventura.org> wrote: > Hello all, > > > My hospital is considering expanding our sepsis screening so that a > VBG+Lactate is checked for every patient with a positive sepsis screen > (instead of lactate alone). Have any other hospitals done this? Does > anyone have a second set of criteria for sicker patients for whom VBG is > ordered? > > > Thanks, > > > Richard Rutherford, M.D. > Quality Medical Director, Ventura County Medical Center > 3291 Loma Vista Road, Ventura, CA 93003 > (805) 665-8234 (cell) > (805) 652-6096 (office) > > ___ > Sepsisgroups mailing list > Sepsisgroups@lists.sepsisgroups.org > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > > ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] Impact of ProCESS study on your protocols
Hi Sue, The study has certainly generated a buzz. For objective, serious students of this disease, however, the study should raise serious concerns about protocol, data, and conclusions. I'm sure these will be addressed in medical and other nursing forums in the months to come. A few comments or questions as examples: 1) Usual care has been irrevocably changed since publication of the EGDT study in 2001, as well as guidelines from SSC supported by many of our professional societies. Indeed sepsis management protocols existed in many of the ProCESS hospitals, so the control groups, protocol-based (PB) standard care and usual care, were treated by physicians well versed in EGDT protocols. 2) The mortality rates in each study group were unexpectedly and remarkably low, around 20%, and probably not representative of the mortality rates for similar patients in most US hospitals. As a result of the low mortality rate, some question whether the study was adequately powered to examine differences between study groups, and whether the study is generalizable to 5000 US hospitals. Moreover, why abandon measures that contributed to such impressive mortality reductions? Are we immune to regressive behavior if practice guidelines are relaxed or removed? 3) The protocol instruction for the first 6 hours was to avoid central line placement, CVP measurement, and ScvO2 in both control groups, PB standard care and usual care, unless peripheral access was inadequate. Yet, over 55% of patients in these groups received them for unstated reasons. One might reasonably speculate they were placed for hypotension and administration of vasopressors. Not stated, however, is how often these lines were utilized for CVP measurements that confirmed or guided resuscitation. In the transcript of a recent NQF conference call, available to the public, an author of the study stated CVP measurements were documented in about 1/3 of the control patients but were not used to guide therapy as evidenced by the lack of followup measurements. However, almost any experienced clinician will act similarly on some single measurements - a patient with a CVP of 3 on vasopressors will almost always receive volume. Also not reported are the number of control patients with lines who had ScvO2 measurements, except for the few who received continuous oximetry lines. It also remains possible that blood sample measurements of ScvO2 were utilized in control patients, but this is not addressed in the manuscript. We don't know how often CVP and ScvO2 measurements were made in control patients with central lines before randomization. We don't know how often clinicians acted on CVPs estimated by bedside neck exam, vertical column height of blood in the lines that were inserted, or IVC dimensions and change with respiration. We don't know how many lines, CVPs, and ScvO2s were added in the control groups after the protocol instructions expired at 6 hours. It is still possible and beneficial to rescue an inadequate resuscitation beyond 6 hours. In short, we don't know enough about management of the control groups. 4) Protocol non-adherence was reported in 11.9% but information in the appendix suggests higher. MAP goals were achieved in only 83%. Overall bundle compliance is not reported. In short, we don't know enough about the quality of management in the EGDT group. 5) Not reported are statistical comparisons between all study patients with lines versus without, control patients with lines versus without, and each of the 2 control group. So in summary, care in any of the study groups is not adequately described, and care in the control groups appears to be significantly contaminated by EGDT. I for one do not favor protocol changes on the basis of this study at this time, and I know for a fact that I have a lot of company. Thanks Ron Elkin MD California Pacific Medical Center San Francisco, CA On Thu, Jul 17, 2014 at 6:23 AM, Sue Beswick sbesw...@ghs.org wrote: Is anyone adapting their protocols with the findings that came out this year with the ProCESS study? We are looking at making some changes. Sue *Sue Beswick APRN, MS, CCNS, CCRN* CNS Critical Care Greenville Health System 701 Grove Road l Greenville, SC 29605 Office: 864-455-4884 ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] Fluid Bolus in pts. with weight 200 kg
A few considerations regarding fluid resuscitation in the obese otherwise: 1) Muscle and solid organs are 75-85% water and densely vascular. Fat is 10% water and much less vascular. Distribution of newly administered isotonic fluid such as normal saline will be limited to the extracellular space. With normal capillary permeability and osmolality this distribution will be roughly 2/3 extravascular and 1/3 intravascular. The fractional distribution will increase to the extravascular space if capillary permeability is increased or osmolality is decreased, as in septic patients. 2) Lean body mass is increased in the obese by as much as 40% in some estimates. Predicted ideal body weight derived from height will underestimate true lean body mass in the obese. 3) Blood volume is increased in the obese in proportion to weight and may be as useful a number as any for estimating a necessary resuscitation volume in sepsis. The Nadler formula has been utilized to calculate blood volume in stable patients. 4) Most studies addressing resuscitation volumes utilize actual body weight. The observed range to reach a target (such as CVP) is very large, as evidenced for example by the large standard deviations in the Rivers EGDT study. 5) The initial fluid bolus recommended for resuscitation in sepsis seems to be an empirical estimate of what is prudent rather than evidence based. The only bolus referenced in the Rivers trial was the 20 ml/kg actual body weight in 30 minutes, an amount used only to reject from the study those who were initially hypotensive but responded to fluid. To be sure, an initial bolus may serve a useful purpose by moving patients more quickly towards resuscitation pressure, volume or perfusion goals. Determination of the actual volume required to reach those goals will be facilitated by early monitoring. Any fluid prescription without monitoring is at best a guess at what will be required, and influenced by a myriad of constantly changing interactive variables such as capillary permeability, source control, vasodilation, cardiac depression, coagulopathy, microvascular mitochondrial dysfunction and reversibility, comorbidities and genetic predisposition. Ron Elkin MD California Pacific Medical Center San Francisco On Thu, May 29, 2014 at 12:59 PM, Terry Clemmer terry.clem...@imail.org wrote: We use predicted body weight calculated from the height rather than actual body weight. It is only the lean body mass that counts. Terry P. Clemmer, MD Director: Critical Care Medicine LDS Hospital Professor of Medicine University of Utah School of Medicine Salt Lake City, Utan 84143 Work Phone: 801-408-3661 Work Fax: 801-408-1668 *From:* Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] *On Behalf Of *Kelsey K. Solano *Sent:* Wednesday, May 28, 2014 8:05 AM *To:* sepsisgroups@lists.sepsisgroups.org *Subject:* [Sepsis Groups] Fluid Bolus in pts. with weight 200 kg I am wondering whether there are any recommendations regarding fluid resuscitation in patients weighing 200 Kg? Our physicians have expressed concern about the recommended fluid bolus for patients who are 200 Kg and potential for CHF exacerbations. Are there any resources that address this concern or any modifications for this patient population? Also, is it always recommended to go with 30 ml/kg based on current weight or should we be calculating ideal weight when determining bolus volume? Currently we are using the patient's actual weight on admission for bolus calculations. Any clarifications regarding the fluid bolus would be greatly appreciated. Thanks, Kelsey K. Solano Sepsis Coordinator Email: solan...@sjrmc.com Office: 574-335-2438 ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] Sepsis Care in third world countries
Modest suggestions to guide fluid administration in resource poor areas - or in resource rich areas prior to line insertion: - Physicians of the dinosaur era used to look at neck veins. CVP can thus be estimated in 90% of people to within +/- 4 cm H2O (3 mm Hg) in about 90% of those. These skills can be resurrected. If neck veins can't be seen the hand can be elevated to the point where venous distention disappears. Vertical distance from the sternal angle + 5 cm H2O (4 mm Hg) is a reasonable estimate of CVP. Caution required especially with tricuspid regurgitation. - We can also refine bedside evaluation of the adequacy of perfusion and volume - mottled skin, acral temperature, capillary return, urine output, assessment of thirst, mucous membranes in non-mouth breathers, sometimes skin turgor. Max Weil published a paper showing a reasonably good correlation between the difference between ambient and big toe temperatures and cardiac output measured by indicator dilution technique (Temperature of the great toe as an indicator of the severity of shock. Joly HR, Weil MH. Circulation 1969, 39:131). - Poor perfusion may merit a carefully monitored fluid trial even if CVP is thought to be elevated - the mortality risk of under-resuscitation may greatly exceed that of fluid overload in many if not most clinical circumstances. Thanks Ron Elkin MD On Tue, Mar 11, 2014 at 3:13 AM, richardlevra...@comcast.net wrote: Good morning all, I'll be traveling to Haiti in May and I was wondering if anyone out there has examples/protocols for care of sepsis patients in those regions where access to resources is sparse. I know that's been an aim of SSC moving forward. Obviously, the technology in these areas would likely not permit measurement of CVPs/ScVO2, etc, but front-loading of fluids and early antibiotics may be feasible with some education of local practitioners. Any ideas would be much appreciated. Thanks, Rich Levrault, DO -- *From: *Ron Elkin elkin@gmail.com *To: *Karin Molander kmoland...@gmail.com *Cc: *Sepsisgroups@lists.sepsisgroups.org *Sent: *Sunday, March 9, 2014 2:12:01 PM *Subject: *Re: [Sepsis Groups] Lactates of 2 or greater being discharged or admitted to the floor I believe the SSC data base documents a 23% mortality rate for severe sepsis with normal lactate, normal BP at presentation. There are a number of observational studies in similarly ill severe sepsis patients, including that of SSC, documenting a mortality penalty associated with triage to the floor before transfer to ICU as compared to triage directly to ICU. I'm aware of no studies showing equivalent or better outcomes for severe sepsis on telemetry on the floors as compared to ICU, even for the not-so-ill patients. I'm aware of no studies randomizing patient assignments to ICU, step-down, telemetry, floors and home, and certainly no publications advocating home. In contrast, the mortality rate at Intermountain Health was 8.7% - 9.7% for *combined* septic shock and severe sepsis (lactates 2.0-3.9), with triage to ICU, Miller RR et al. AJRCCM July 2013. I'm not sure triage to telemetry adds much outcome benefit to to placement on the floors. The outcome benefits of ICU and step-down are perhaps more likely related to greater frequency of vital signs monitoring (Q1-2H vs Q4H on floors and many telemetry units) as well as triage to areas where RNs and MDs are much more familiar with recognition and management of severe sepsis. Based on the above, it seems prudent to triage all patients with severe sepsis to ICU or stepdown whenever permitted by bed availability. While lactate elevation and/or hypotension are important signs of mortality risk, their absence hardly portends a benign outcome. Ron Elkin, MD California Pacific Medical Center San Francisco On Thu, Mar 6, 2014 at 8:38 AM, Karin Molander kmoland...@gmail.comwrote: Does anyone have data/article references regarding lactates of 2 being sent home or admitted to a floor bed rather than Telemetry bed? -- Karin H. Molander MD Mills-Peninsula Hospital Sutter ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] SIRS criteria
Studies show that 15% of cases of severe sepsis and septic shock - defined as acute organ dysfunction due to infection - have 0 or 1 sign of SIRS, rather than the consensus-required 2 or more. These are often the elderly or immunosuppressed. In this context the difference between 38 and 38.3 degrees centigrade seems immaterial. Ron Elkin, MD California Pacific Medical Center San Francisco On Fri, Feb 21, 2014 at 2:44 PM, Ron Daniels r...@sepsistrust.org wrote: 38: Bone, 1992. 38.3: Levy, 2001. Same consensus group, 10 years, different lead authors. 38.3 is current. R Dr Ron Daniels Chair: UK Sepsis Trust CEO: Global Sepsis Alliance Sent on the move from my iPhone, excuse brevity! On 19 Feb 2014, at 15:40, Seckel, Maureen msec...@christianacare.org wrote: Simple question. Why is SIRS criteria for Temperature written as 38 degrees for high in some articles and medical calculators and 38.3 in others. Which really is it? The SS Campaign guidelines and data base uses 38.3. Thanks, Maureen A. Seckel, APN, ACNS-BC, CCNS, CCRN CNS Medical Pulmonary Critical Care Sepsis Coordinator Christiana Care Health System 4755 Ogletown-Stanton Road 3E29 Newark, DE 19718 Office 302 733-6023 ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] question about initial fluid bolus
The recommendation for the initial fluid bolus is based upon expert opinion and actual body weight. There was no specific bolus prescribed in the original EGDT study. The only bolus referenced in that study was the 20-30 ml/kg/30 min bolus used to exclude from the study hypotensive patients who responded to the bolus. That, of course, does not mean that all patients in the study received no bolus, but whatever unspecified bolus they received, and total 6 hour fluid requirements, were determined by judgments about severity and phase of illness, comorbidities, and most importantly the amount of fluid actually required to achieve resuscitation goals. EGDT group required a mean of 5 L at 6 hours but standard deviations were huge with estimated range of 1 - 11 L. Ron Elkin MD California Pacific Medical Center San Francisco On Wed, Oct 23, 2013 at 5:04 AM, Brown, Sheree sheree.br...@allegiancehealth.org wrote: Several physicians I work with insist that the initial fluid bolus (30 mL/kg) should be based on ideal body weight, not actual body weight. Where can I find specific documentation regarding this issue? Thanks, Sheree ** ** ** ** -- *Sheree Brown MSN, RN, CNL* Clinical Quality Specialist, Emergency Services Performance Excellence Phone: 517 788-4800 ext. 4209 Pager: 517 534-0127 Fax: 517 788-4715 sheree.br...@allegiancehealth.org http://allegiancehealth.org [image: email-signature-mcgaw] ** ** -- This e-mail message and any attachment(s) is intended only for the individual(s) to whom it is addressed and may contain information that is privileged, confidential or proprietary in nature. Any unauthorized disclosure, copying or distribution of this e-mail or the content of this message is prohibited. If you have received this e-mail message in error, please immediately notify the sender at the e-mail address above, permanently delete this e-mail and destroy any copies of this e-mail and attachments in your possession. This electronic message (“e-mail”), including the typed name of the sender, does not constitute an electronic signature unless there is a specific statement to the contrary included in this e-mail. ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] Timing of Antibiotic Administration
There are subtlties of antibiotic administration that must be considered: 1) While most centers mark start time at spiking the bag of the first broad spectrum antibiotic for infusion, the patient marks start time at infusion of a sufficient dose of antibiotic effective against the organism responsible for the clinical syndrome. Each center would benefit from looking at their in-house data to ensure administration of effective agents. Ceftriaxone is useless if the problem is MRSA pneumonia. 2) In real time one seldom knows the organism and which of 2 or 3 selected antibiotics will be effective. Many centers have implicit or explicit rules prohibiting rapid administration or simultaneous administration of 2 or more agents. This may be to better allow analysis of potential adverse side effects or allergic reactions. The patients, however, may be better served by disregarding these rules and rapidly administering agents simultaneously. As an alternative, at least we could be more vigilant about first giving the antibiotic effective against the most highly suspected organism. 3) It is interesting to note that some antibiotics result in more rapid killing and therefore faster release of endotoxin. I'm unaware of studies or data, but one might wonder if the price for faster killing might be a higher chance of early clinical deterioration. Thanks Ron Elkin, MD California Pacific Medical Center San Francisco On Sun, Sep 22, 2013 at 4:27 PM, Mary Draper mary.dra...@johnmuirhealth.com wrote: We time it off of getting started. Infusion times can vary but start time is easier to time off. Mary Draper RN BSN CCRN Quality Manager-Best Practice Support Quality Management Supervisor Office (925) 674-2045 Cell (925) 451-8792 Fax (925) 674-2373 mary.dra...@johnmuirhealth.com On Sep 22, 2013, at 3:32 PM, Muhr, Lori lm...@jpshealth.org wrote: I am wondering what everyone else is using for their antibiotic time. Is it when it is initiated, while it is infusing, or after it is infused? We had a lively discussion in our Sepsis meeting this week with each Physician stating an argument for the different timeframes. ** ** I am looking to see what you are doing at your facility. Thanks ** ** ** ** ** ** ** ** Lori J. Muhr MSN, MHSM/MHA, APRN, ACNS-BC, CCRN, CEN Clinical Nurse Specialist - Clinical Coordinator – Sepsis Quality Services 817-702-1717 lm...@jpshealth.org ** ** -- This electronic transmission and any attached files are intended solely for the person or entity to which they are addressed and may contain information that is privileged, confidential or otherwise protected from disclosure under applicable law. Any review, retransmission, dissemination or other use, including taking any action concerning this information by anyone other than the named recipient, is strictly prohibited. If you are not the intended recipient or have received this communication in error, please immediately notify the sender by return email and delete the original message from your system. ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] Pre-hospital Antibiotic Administration
Good idea, perhaps best for the sickest with the longest travel times. The many logistic considerations might include degree of certainty of diagnosis, drug allergy history, instant access to various antibiotics, help with selection of antibiotics by an experienced physician, buy-in by the receiving medical centers, compromise of culture results, adequacy of IV access to handle antibiotics without compromise of fluid administration. Ron Elkin MD California Pacific Medical Center San Francisco On Mon, Sep 30, 2013 at 4:31 AM, Josie Gray jg...@uni.brighton.ac.ukwrote: Hi there, I am a third year student Paramedic, studying at the University of Brighton. An assignment we have been given involves researching and suggesting an improvement our local ambulance service can make to improve patient care. I recently attended a male suffering signs of severe sepsis. He had been getting progressively worse following an untreated chest infection and had been in the condition we found him for around 3 hours before his wife decided to call an Ambulance. We initiated a fluid challenge and took him to AE under a blue light priority. Along with all our regular checks. My thoughts from this were, had paramedics been allowed to give broad spectrum antibiotics, would this have been of benefit to the patient at all as apposed to receiving these in hospital, considering his potential to deteriorate rapidly? Our transport time being 20-25 minutes. And would this have given the hospital more time to complete other tasks required for this patient, e.g blood cultures, imaging etc and enable him to get the care he needs as quickly as possible? I would be very grateful for your opinion on this and if you would have any suggestions or recommendations I could research into, on what more the Ambulance service can do for this group of patients? Kind Regards, Josie Gray Third year student Paramedic, University of Brighton. ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] Time Zero
I believe SSC defines Time Zero as triage time for ED patients and time of diagnosis for patients elsewhere in the hospital. In support of ED triage time, one would argue that it is a simple, easily determined time in all hospitals and avoids the inevitable endless,debate about the accuracy of time of diagnosis. The counter-argument has been that this definition will not account for and will unduly penalize those confronting patients with true delays in development of the syndrome after arrival in ED. The clarity of triage time has prevailed as the standard. The expectation is that both iatrogenic and true delays in diagnosis will haunt us all and the closer we can push initiation of treatment to the indisputable time of triage, the better the outcome expected at each center. From a quality improvement perspective, however, it seems unreasonable to expect caregivers to act appropriately before arriving at a working diagnosis of severe sepsis or septic shock. For this reason, our center chose to examine two questions, each with different implications for improving performance: 1) Did the working diagnosis trigger appropriate and timely therapy? If not, specific protocol, personnel, and systems issues must be examined and corrected. 2) Was the working diagnosis timely,or was it delayed due to nurse/physician/systems error? If delayed, distinctly different issues must be examined. A delayed diagnosis may fall into 3 categories: i) Potential delay - example: someone with SIRS and a potential source of infection with delayed testing for later-documented organ dysfunction. ii) Real delay - example: organ dysfunction was timely documented but not recognized as severe sepsis. iii) Both i and ii. . I can't recall literature addressing this, but we estimate delay in diagnosis in roughly 20% of our patients due to error. The analysis has helped us better categorize and address our problems. On a different note, it is well established that about 15% of patients with severe sepsis or septic shock lack 2 or more signs of SIRS. These are largely elderly and/or immunosuppressed patients. SIRS remains an important screening tool, but when absent, severe sepsis must still be considered a potential cause of unexplained organ dysfunction - in apparent contradiction of consensus definitions. My $0.02 Ron Elkin MD California Pacific Medical Center San Francisco, CA : On Wed, Feb 6, 2013 at 12:34 PM, Crittenden, Andrea L andrea.critten...@providence.org wrote: We use ICD-9 codes Severe Sepsis 995.92 or Septic Shock 785.52. ** ** Andrea Crittenden, RN Quality Improvement Specialist Providence St. Peter Hospital- Olympia, WA 360-486-6465 ** ** *From:* sepsisgroups-boun...@lists.sepsisgroups.org [mailto: sepsisgroups-boun...@lists.sepsisgroups.org] *On Behalf Of *Hunter, Patricia *Sent:* Wednesday, February 06, 2013 9:33 AM *To:* Taylor, Barbara A; Ron Daniels *Cc:* sepsisgroups@lists.sepsisgroups.org *Subject:* Re: [Sepsis Groups] Time Zero ** ** Our Hospital currently performs Sepsis audits on ED and IP. We are relying on clinical personnel to capture sepsis patients for the audit. There is much discussion about moving the audit to more retroactive and pulling those patients with codes specific to Sepsis. Is anyone doing auditing relying on coding solely? If so, what ICD9 Codes are you using to pull data? ** ** Thanks, Pat ** ** ** ** Patricia Hunter, RN Clinical Data Analyst Performance Excellence Mercy Medical Center - Des Moines, Iowa 515-643-2206 ** ** *Life is not about waiting for the storms to pass... it's about learning to dance in the rain!* ** ** ** ** This electronic mail and any attached documents are intended solely for the named addressee(s) and contain confidential information. If you are not an addressee, or responsible for delivering this email to an addressee, you have received this email in error and are notified that reading, copying, or disclosing this email is prohibited. If you received this email in error, immediately reply to the sender and delete the message completely from your computer system. -- This message is intended for the sole use of the addressee, and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you are not the addressee you are hereby notified that you may not use, copy, disclose, or distribute to anyone the message or any information contained in the message. If you have received this message in error, please immediately advise the sender by reply email and delete this message. ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
Re: [Sepsis Groups] flu and sepsis screening
With respect, the problem with asking whether the generally healthy college kid with SIRS criteria and a strep throat really needs a lactate and blood cultures is that it presupposes a correct and benign diagnosis requiring only simple outpatient therapy. The question correctly implies a group at low risk, but we will undoubtedly make mistakes. A rare patient will return to be recharacterized as strep bacteremia or pneumonia with organ dysfunction, peritonsillar abscess, or meningococcal meningitis. In some of these cases, perhaps, earlier hints of serious trouble were overlooked. We of course will be held responsible, and hold ourselves responsible, for our oversights. There would be fewer of them if we were more vigilant. I am often reminded that expert opinion is regarded as the lowest quality of evidence. Even in groups at higher risk for severe sepsis, however, many of us assume our clinical judgments (which usually fall short of expert opinion) will distinguish those who are really sick from those who are not. I think this is an error. In all likelihood, some of us are better at this game than others, but undoubtedly we all have lapses. Few if any of us have data regarding the accuracy of our own clinical judgments, yet many if not most of us seem quite eager to overestimate our own abilities even when it is the patient and family who bear the risk. The purpose of a screen is to detect the maximum number of cases - and perhaps thereby protect patients from our sometimes faulty clinical judgment. SIRS /or infection should often prompt an additional screen for organ dysfunction including an elevated lactate. The treating physician or nurse makes the screening decision, and all cases do not have to be directed to the ED. The cost of a lactate in our hospital is well below $1.00. A normal lactate does not exclude severe sepsis. An elevated lactate can seldom be dismissed. Some maintain that lactate is a better ED screen for severity of illness than many of the standard ED tests we run, and a better predictor of who should stay, length of stay, cost of stay, development of multi-organ failure, and death. Blood cultures are substantially more expensive, results are delayed, and so they may deserve a little more thought before ordering, but we've all seen patients called back to the hospital for positive blood cultures. Should we always follow SIRS /or infection with a screen for organ dysfunction? Always and never are unforgiving rules that may not work well here. The answer may partially depend on where the patient is identified. Already hospitalized patients are in a special risk group with perhaps a better reason to screen in the great majority. I'd agree the answer is probably no for many low grade fevers, sore throats and runny noses in the ED or office. One practical issue is that EDs or offices could become overcrowded with people at low risk waiting for their organ dysfunction screens to return while delaying necessary attention from those who really need it. Should rare mistakes result in always screening subsequent low risk patients with the identical clinical picture for evidence of organ dysfunction? Probably not, but it should lead to a more thorough search for those subtle hints of real trouble, reasons to complete the screening, and an early return visit or call for some of those considered safe for discharge. Just my $0.02 Ron Elkin, MD Pulmonary/Critical Care California Pacific Medical Center San Francisco On Fri, Dec 14, 2012 at 6:32 AM, Steve Chabala s...@comcast.net wrote: I think Sue's question gets at the larger question of the need for testing of ALL patients with SIRS criteria and evidence of infection. All such patients should be directed by their primary care doctors to come to the ER for sepsis evaluation? Does the generally healthy college kid with SIRS criteria and a strep throat really need a lactate and blood cultures drawn? Probably not. I'm curious to know if there is any literature to address this sort of issue. When does sepsis screening yield to common sense? Steve Chabala D.O., F.A.C.E.P. ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ___ Sepsisgroups mailing list Sepsisgroups@lists.sepsisgroups.org http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
